Statutory Referral Form for SafeCare

Your referral and any subsequent contact will be confidential in order to protect your privacy. Information about our Privacy Policy is available upon request.

NOTE: Our Social Workers will endeavour to get in contact within 2 weeks of receiving your referral

Referrer Details:

Name of Referrer:(Required)

Relationship to Client/s:(Required)

Organisation/Site Location(Required)

Work Contact Number(Required)

Work Email(Required)

Line Manager/Supervisor(Required)

Site Manager(Required)

The cost of this programme is $5000 + GST. I confirm that funding is available for this referral:(Required)

YES

Purchase Order Number (If Applicable)

Administration Contact(Required)

Are the parents / caregivers aware this referral has been made?(Required)

Yes

Primary Parent / Caregiver

Full Ingoa (Name) of client(Required)

Date of Birth(Required)

Ethnic Group/s(Required)

Iwi (If Applicable)

Contact Number(Required)

Email Address(Required)

Current Living Address(Required)

Pronouns you would like us to use for you:(Required)

She/Her

He/Him

They/Them/Their

Other Parent / Caregiver

Full Ingoa (Name) of client

Date of Birth

Ethnic Group/s

Iwi (If Applicable)

Contact Number

Email Address

Current Living Address

Pronouns you would like us to use for you:

She/Her

He/Him

They/Them/Their

Pēpi / Tamariki

Full ingoa(Required)

Date of Birth(Required)

Full ingoa

Date of Birth

Full ingoa

Date of Birth

Full ingoa

Date of Birth

Full ingoa

Date of Birth

Full ingoa

Date of Birth

What are the key issues and needs that have been identified for this whānau?

Are there Legal orders in place? (click what is applicable and provide details)

Custody Orders(Required)

Yes

Parenting Orders(Required)

Yes

Court Appointed Access(Required)

Yes

Protection Orders(Required)

Yes

Trespass Orders(Required)

Yes

Are there Parenting Concerns(Required)

Yes

Please Include any care and protection concerns

Other (Please Specify)

Is the Whānau currently involved with Oranga Tamariki?(Required)

Yes

Has the Whānau previously been involved with Oranga Tamariki?(Required)

Yes

Has the Whānau used Home & Family services in the past?(Required)

Yes

Has the Whānau experienced family violence?(Required)

Yes

Are there concerns regarding mental health for the Whānau?(Required)

Yes

What interventions, if any, has the Whānau had previously?(Required)

What are their strengths, resources, supports and protective factors?

Is there other relevant information for us to be aware of, including safety/legal issues?(Required)

Yes

Will a parenting assessment be required?(Required)

Yes

Other Whanau / Caregivers / Professionals / Agencies Involved:

Name

Role / Agency

Phone Number

Name

Role / Agency

Phone Number

Name

Role / Agency

Phone Number

Home & Family Charitable Trust PO BOX 287 Christchurch e: [email protected] web: www.homeandfamily.net.nz